Introduction to Carbohydrate Counting. Insulin adjustment

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2 Introduction to Carbohydrate Counting Carbohydrate counting can be a useful tool to help children manage their blood glucose levels. All carbohydrates (starches and sugars) are digested to glucose which is released into the blood stream causing a rise in your blood glucose level. By counting the amount of carbohydrate in food, you can learn to predict the rise in your blood glucose level after eating different types and amounts of carbohydrate. This can be used to calculate the amount of insulin you need to give. The aim of carbohydrate counting is to allow the children to choose the type and amount of carbohydrate they wish to eat and be able to match it with the appropriate amount of insulin. It is still important to have a healthy balanced diet. Insulin adjustment In order to use this system, the children need to be on a Multiple Daily Injection (MDI) regimen. This involves giving rapid acting insulin with meals and a longer acting, slow release background insulin once or twice daily. The dose of rapid acting insulin given will depend on their pre-meal blood glucose level and the amount of carbohydrate eaten at their lunch time meal. The dose of your background slow release insulin will not change as frequently as it is not directly linked to your carbohydrate intake. This approach requires a lot of commitment and time from all the school staff as you all will need to learn about the amount of carbohydrate in different foods.

3 What can you eat? The foods suitable for people with diabetes are ordinary ones that can be bought in the supermarket. You may be advised to change the way you cook some foods or alter the ingredients used in recipes but the basic foods themselves will mostly be those you have always eaten. Enjoy eating a variety of foods Food for a healthy life You need sufficient calories, protein, vitamins and minerals for daily living and for normal growth in children and young people. The plate model shows the different proportions of food groups to aim for in your daily diet Crown copyright material is reproduced with the permission of the Controller of HMSO and Queen s Printer for Scotland.

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5 Which foods contain carbohydrate? Carbohydrate is found in the following foods: Starchy carbohydrate Cereal Starch Grains e.g. wheat, barley, rye, rice and oats Bread and flour products e.g. biscuits, cakes, pastries Breakfast cereals Pasta Noodles Couscous Vegetable starch Potatoes and potato products, sweet potato, yam Sweetcorn Legumes and pulses e.g. baked beans, red kidney beans, peas and lentils Cereal and vegetable starches are digested to glucose Sugary carbohydrate These include both natural sugars found in food and sugars added to food. Natural sugars found in food: Fruit and fruit juices The sugars found in fruit are fructose and sucrose Milk and milk products e.g. yoghurt, mousse, custard and ice cream The sugar found in milk is lactose Sugar added to food: Sucrose is the sugar added to many foods to make them sweet e.g. sweets, chocolates, biscuits, cakes, desserts, jams, marmalade and sugary drinks Sucrose and lactose are digested to glucose

6 Quick guide to identifying carbohydrate in your diet Foods Containing Carbohydrate These foods contain significant amounts of carbohydrate and need to be counted in your diet Cereal Starch Breakfast cereals Bread and flour products Rice and grains e.g. couscous Pasta Noodles Vegetable Starch Potatoes and potato products Beans and pulses Sweet potato Yam Sugary Carbohydrates Fruit and fruit juices Milk and milk products Foods containing added sugar e.g. cakes, sweets and chocolates Foods Containing Minimal Carbohydrate These foods contain minimal amounts of carbohydrate and do not need to be counted in your diet Protein Meat Fish Eggs Cheese Nuts Soya Fat Butter Margarine Cream Oils Most vegetables Salad

7 Calculating Carbohydrate Carbohydrate can be identified and counted in food using: Food labels Carbohydrate Ready reckoner Internet sites and manufacturers information Books and leaflets Food weighing scales

8 Food Labels Food labels are very useful for determining the amount of carbohydrate in foods: When you know your portion size e.g. 25g packet of crisps or When you do not know the portion size using the carbohydrate value per 100grams of food If you know the portion size of the food: A food label always lists nutrients per 100g of the food, but also often lists them per portion. The example below shows the food label from a packet of crisps Per 25g Pack Energy 548Kj 131 kcal Protein 1.8g Carbohydrate 12.5g of which sugars 0.6g Fat 8.3g of which saturates 0.7g of which mono-unsaturates 6.5g of which poly-unsaturates 0.7g Per 100g 2190 kj 525kcal 50.0g 2.5 g 33.0g 2.6 g 25.9g 2.8g Fibre 1.0g 0.50g Sodium 0.13g 1.27g 12.5g This packet of crisps contains 12.5g of carbohydrate per 25g packet When calculating the carbohydrate content of a food, it is important you use the TOTAL carbohydrate value and not the of which sugars value.

9 Using the information on the food label The food label can also be used to determine how much carbohydrate is in 100g of a food. This can then be used to calculate the amount of carbohydrate in your food portion (see below) How to work out the amount of carbohydrate in a portion You will need a calculator, digital weighing scales and the food label. Step 1 Using a food label, find out the amount of carbohydrate in 100g For example: Cooked Pasta nutritional information Energy Protein Carbohydrate of which sugars Fat Fibre Per 100g 22g Step 2 Weigh your portion in grams using digital scales. For example: 200g Step 3 Divide the amount of carbohydrate per 100g (step 1) by 100. For example: 22g 100 = 0.22 Step 4 Then multiply that answer by the portion size (step 2). For example:0.22 X 200g = 44 g So there is 44 g of carbohydrate in a 200g portion of pasta.

10 Using the information of the food label when you do not know your portion size The food label can also be used to determine how much carbohydrate is in 100g of a food. This can then be used to calculate the amount of carbohydrate in your food portion (see below) How to work out the amount of carbohydrate in a portion You will need a calculator, digital weighing scales and the food label. Step 1 Using a food label, find out the amount of carbohydrate in 100g For example: Cooked Pasta nutritional information Energy Protein Carbohydrate of which sugars Fat Fibre Per 100g Step 2 Weigh your portion in grams using digital scales. g Step 3 Divide the amount of carbohydrate per 100g (step 1) by 100. Step 4 Then multiply that answer by the portion size (step 2). So there is..g of carbohydrate in a.g portion of pasta.

11 Manufacturer s information websites Many food manufacturers provide information on the carbohydrate content of their foods. A selection can be found at the websites below Burger King Domino s pizza Harvester KFC McDonalds Pizza Hut Starbucks Subway sandwiches Wetherspoons

12 Books and Leaflets There are a number of different books available which list the carbohydrate content of different foods. Some list the carbohydrate values per portion and others per 100g of food. Some examples include: Collins Gem Fat and Calorie Counter. Collin Gem Published 2006 Collins Gem Carb Counter ISBN The Fat, Fibre and Carbohydrate Counter: The Essential Guide to Healthy Eating. Dee Stanford ISBN The Calorie, Carb and Fat Bible Juliette Kellow, Lyndel Costain and Rebecca Walton. Weight Loss Resources 2007 ISBN Carbs and Cals. A Visual guide to carbohydrate counting and calorie counting for people with diabetes Chris Cheyette Yello BALOLIA ISBN:

13 Nutrition Scales Nutrition scales can be used to calculate the amount of carbohydrate in meals and snacks. They can be particularly useful in the following situations: When trying to work out the amount of carbohydrate in a food that does not have a fixed portion size such as pasta or rice. When working out the amount of carbohydrate in foods that vary considerably in their size such as baked potatoes or bananas. When plating up a meal that contains more than one type of carbohydratecontaining food such as Jacket potato and beans or roast potatoes and Yorkshire puddings. When working out the amount of carbohydrate in a home-made recipe such as a cake containing flour and sugar.

14 How do they work? Typically a codebook comes with the scales. The food is placed on the scales and the corresponding code for that food is inputted into the scales. The scales will then calculate the amount of carbohydrate in the portion. Where can I get nutrition scales from? Your Dietitian may be able to help you find a set of scales. There are also a number of stores online that stock nutrition scales. Salter sells a few different types of nutrition scales ranging from around Products shown are the Salter Nutri-Weigh Slim Scale 1406 and the Salter 1440 Nutri-Weigh & Go Dietary Computer Scale. Available at: Rosemary Conley sells a set called EnerGi Nutri-Scales for around 40. Available at: Lloyd s Pharmacy Nutritional Scale. Cost approx My Weigh Nutriscale Dietary Scale. Cost approx 20 Available at:

15 Sample meals containing carbohydrate Below are some examples of different types of meals illustrating the amount of carbohydrate found in different types of foods Breakfast Food Portion Size Carbohydrate per portion (g) Apple Juice 1 glass / 200ml 10 Weetabix 2 biscuits 30 Semi Skimmed Milk 1 glass / 200ml 10 Boiled Egg 1 egg Negligible Wholemeal Bread 2 medium slices 30 Margarine 30g Negligible Total Carbohydrate 80 Packed Lunch Food Portion Size Carbohydrate per portion(g) Pitta bread 2 medium Pitta 60 Chicken salad filling 60-90g Negligible Cherry tomato 1 medium Negligible Fromage Frais 1 small pot/60g 10 Banana 1 medium /100g 25 Cereal Bar 1 bar/25g 20 Apple 1 medium /150g 15 Total Carbohydrate 130 Evening Meal Food Portion Size Carbohydrate per portion (g) Bolognaise Sauce 90g Negligible Cooked Spaghetti 5 tablespoons 50 /220g Grated Cheese 30g Negligible Green Salad 30g Negligible Garlic Bread ¼ baguette 20 Fruit Yoghurt 1 pot / 125g 20 Total Carbohydrate 90

16 Calculating your Insulin Dose In order to adjust your rapid acting insulin it is necessary to learn how to: Identify and calculate the amount of carbohydrate in your meals and snacks Calculate the amount of rapid acting insulin required to match the quantity of carbohydrate in the food you are going to eat. Calculate the correction dose of insulin you require depending on your premeal blood glucose level Insulin: Carbohydrate Ratio Once you have learned how to count the amount of carbohydrate in your meals, you can calculate the amount of insulin needed. Everyone has a different insulin requirement. e.g. 1 unit of rapid acting insulin is required for every 10 grams of carbohydrate This is known as the insulin to carbohydrate ratio. Your Diabetes team will work this out with you. Insulin Correction Dose If your blood glucose level is too high before a meal, you will need to give additional insulin to bring it down to within the normal range (4-7mmol). e.g.1 unit of rapid acting insulin is needed to lower the blood glucose by 3 mmol/l This is known as your insulin correction ratio. Your Diabetes team will work this out with you. Hypos It is important that you do not correct a high blood glucose level if you have had a hypo within the last hours. If your blood glucose level is below 4mmol/l, you must treat the hypo before you have your meal. You may consider giving less insulin.

17 Contact Information Gill Regan Claire Baker Hannah Fisher Paediatric Dietitians Department of Nutrition and Dietetics Royal Gwent Hospital, Newport, NP20 2UB Telephone

18 Treatment of Hypoglycaemia Hypoglycaemia is when your blood glucose level is less than 4.0mmol/l. If possible, please check your blood glucose level prior to treatment of hypoglycaemia.

19 MILD MODERATE SEVERE If conscious and able to swallow If conscious and able to swallow, but in need of assistance If unconscious and unable to swallow Give 10-20g fast acting carbohydrate. There is 10g carbohydrate in: 50ml Lucozade Energy, or 100ml cola, or 3 glucose tablets, or 2 standard jelly babies (3 mini jelly babies) or 4 fruit pastilles or 8 jelly tots or 2 teaspoons glucose powder mixed with 50ml water / No Added Sugar squash Give 1 tube of glucogel slowly squeezed into their mouth. The gel is easily swallowed. Place patient in recovery position Call for the ambulance. or If you have received training from your nurse, give glucagon using your GlucaGen HypoKit (glucagon) Check that your GlucoGen HypoKit is still in date. If patient is not responding call for the ambulance Wait minutes and recheck glucose levels, and record. If reading is still less than 4.0mmol/l, repeat process Once patient is conscious, follow treatment for moderate or mild hypoglycaemia depending on level of consciousness Once blood glucose level is above 4.0mmol/l, give an extra carbohydrate snack e.g. a piece fruit, a sandwich, 2 digestive biscuits, oat based cereal bar or meal if appropriate What is Hypoglycaemia?

20 Hypoglycaemia means low blood glucose. It is often called a hypo and is defined as a blood glucose level below 4.0mmol/l. Some people don t feel the symptoms of a hypo at this level but it is important to treat any levels below 4 mmol/l. Possible causes of hypoglycaemia: Too much insulin Too little food (e.g. missed or delayed meal or snack) Physical activity Getting very hot or cold Drinking alcohol Signs and symptoms of hypoglycaemia: There are many different signs and symptoms of hypoglycaemia and not everyone will experience them all. Below are some of the signs and symptoms that you may experience: Weakness Hunger Pale face Sweating Shaking Dizziness Large pupils/glazed expression Tingling around the mouth Mood changes e.g. irritability Crying inappropriately Visual disturbance Feeling sick Headache Remember, if you experience any of the above signs and symptoms: Check your blood glucose level. Treat your symptoms of Hypoglycaemia immediately.